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If the pH and bicarbonate to carbonic acid ratio are changed too drastically buy cheap solian 50 mg on line, the body may not be able to compensate generic solian 50 mg on line. Extensive damage to proteins in this way can result in disruption of normal metabolic processes, serious tissue damage, and ultimately death. Hence, the respiratory route is less efficient at compensating for 1272 Chapter 26 | Fluid, Electrolyte, and Acid-Base Balance metabolic alkalosis than for acidosis. Metabolic Compensation Metabolic and renal compensation for respiratory diseases that can create acidosis revolves around the conservation of bicarbonate ions. In cases of respiratory acidosis, the kidney increases the conservation of bicarbonate and secretion of + H through the exchange mechanism discussed earlier. These processes increase the concentration of bicarbonate in the blood, reestablishing the proper relative concentrations of bicarbonate and carbonic acid. In cases of respiratory alkalosis, + the kidneys decrease the production of bicarbonate and reabsorb H from the tubular fluid. These processes can be limited + + by the exchange of potassium by the renal cells, which use a K -H exchange mechanism (antiporter). Metabolic acid-base imbalances typically result from kidney disease, and the respiratory system usually responds to compensate. Metabolic acidosis is problematic, as lower-than-normal amounts of bicarbonate are present in the blood. An appropriate balance of water and solute concentrations must be maintained to ensure cellular functions. If the cytosol becomes too dilute due to water intake by cells, cell membranes can be damaged, and the cell can burst. Hydrostatic pressure is the force exerted by a fluid against a wall and causes movement of fluid between compartments. Passive transport of a molecule or ion depends on its ability to pass easily through the membrane, as well as the existence of a high to low concentration gradient. Most water intake comes through the digestive tract via liquids and food, but roughly 10 percent of water available to the body is generated at the end of aerobic respiration during cellular metabolism. The kidneys can adjust the concentration of the urine to reflect the body’s water needs, conserving water if the body is dehydrated or making urine more dilute to expel excess water when necessary. The ions in plasma also contribute to the osmotic balance that controls the movement of water between cells and their environment. Imbalances of these ions can result in various problems in the body, and their concentrations are tightly regulated. A buffer is a substance that prevents a radical change in fluid pH by absorbing excess hydrogen or hydroxyl ions. Several substances serve as buffers in the body, including cell and plasma proteins, hemoglobin, phosphates, bicarbonate ions, and carbonic acid. What happens in tissues decreases due to sweating, from what source is water taken when capillary blood pressure is less than osmotic in by the blood? Describe the control of blood carbonic acid levels this be if individual ions of sodium and chloride exactly through the respiratory system. Her laboratory results are as actually have elevated or deficient levels of that substance follows: pH 7. Describe the conservation of bicarbonate ions in the as acidosis or alkalosis, and as metabolic or respiratory. Ovulation marks the end of the follicular phase of the ovarian cycle and the start of the luteal phase. Introduction Chapter Objectives After studying this chapter, you will be able to: • Describe the anatomy of the male and female reproductive systems, including their accessory structures • Explain the role of hypothalamic and pituitary hormones in male and female reproductive function • Trace the path of a sperm cell from its initial production through fertilization of an oocyte • Explain the events in the ovary prior to ovulation • Describe the development and maturation of the sex organs and the emergence of secondary sex characteristics during puberty Small, uncoordinated, and slick with amniotic fluid, a newborn encounters the world outside of her mother’s womb. We do not often consider that a child’s birth is proof of the healthy functioning of both her mother’s and father’s reproductive systems. Moreover, her parents’ endocrine systems had to secrete the appropriate regulating hormones to induce the production and release of unique male and female gametes, reproductive cells containing the parents’ genetic material (one set of 23 chromosomes). Her parent’s reproductive behavior had to facilitate the transfer of male gametes—the sperm—to 1280 Chapter 27 | The Reproductive System the female reproductive tract at just the right time to encounter the female gamete, an oocyte (egg). Finally, combination of the gametes (fertilization) had to occur, followed by implantation and development. In this chapter, you will explore the male and female reproductive systems, whose healthy functioning can culminate in the powerful sound of a newborn’s first cry. At fertilization, the chromosomes in one male gamete, called a sperm (or spermatozoon), combine with the chromosomes in one female gamete, called an oocyte. The paired testes are a crucial component in this process, as they produce both sperm and androgens, the hormones that support male reproductive physiology. Several accessory organs and ducts aid the process of sperm maturation and transport the sperm and other seminal components to the penis, which delivers sperm to the female reproductive tract. In this section, we examine each of these different structures, and discuss the process of sperm production and transport.

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However order solian 50 mg line, it is acceptable medical practice not to initiate intensive care if parents so wish order solian 50 mg, following appropriate counselling. Breech position - occurs in about 3% of fetuses when buttocks or lower limb are presented to the birth canal rather than normal cephalic (head-first) position (presentation). Associated increased - perinatal mortality, perinatal morbidity, recurrence in successive siblings Current research suggests that genetically that both men and women delivered in breech presentation at term could also contribute to an increased risk of breech delivery in their offspring. Normally this meconium is defaecated (passed) postnatally over the first 48 hours and then transitional stools from day 4. Premature discharge into the amniotic sac can lead to mixing with amniotic fluid and be reswallowed by Breech Birth the fetus. Necrotizing Enterocolitis Occurs postnatally in mainly in premature and low birth weight infants (1 in 2,000 - 4,000 births). The underdeveloped gastointestinal tract appears to be susceptible to bacteria, normally found within the tract,to spread widely to other regions where they damage the tract wall and may enter the bloodstream. Stillbirth and Perinatal Death Perinatal period is the early postnatal period relating to the birth, statistically it includes the period up to 7 days after birth. In pregnant women anywhere between 2 - 15% have birth weights of greater than 4000 grams (4 Kg, 8 lb 13 oz). Vertex Presentation (cephalic presentation) where the fetus head is the presenting part, most common and safest birth position. Each topic summary is designed for use in conjunction with the relevant didactic lecture given during the rotation. Original and Review Articles – Original, and review articles are provided for residents who seek a more comprehensive understanding of a topic. We recognize that residency is a busy time, but we hope that you will take the time to read articles relevant to the management of your patients. In order to facilitate learning at many levels, several other educational opportunities are available. Tutorials – These are 20-30 minute sessions offered during the rotation that will provide the resident with hands on experience (e. The goal of morning rounds is to develop treatment plans that can be defended by the best available scientific evidence. In addition, morning rounds are an opportunity for residents to test their knowledge, gauge their progress in critical care education, and recognize the limits of the current medical practice. The faculty and fellows of Boston University Pulmonary and Critical Care section hope that you enjoy your rotation in the medical intensive care unit. Management and Optimal Timing of Tracheostomy / Literature Chapters on Cardiopulmonary Critical Care G. During respiration air is humidified reducing atmospheric pressure by 47mmHg to 713mmHg so the maximal inspired partial pressure of oxygen is 149mmHg. Hemoglobin has 4 binding sites for oxygen, and if all are occupied then the oxygen capacity would be saturated. With a normal cardiac output of 5 l/min, the delivery of oxygen to the tissues at rest is approximately 1000 ml/min: a huge physiologic reserve. Dissolved in blood - Dissolved oxygen follows Henry’s law – the amount of oxygen dissolved is proportional to the partial pressure. If this was the only source of oxygen, then with a normal cardiac output of 5L/min, oxygen delivery would only be 15 ml/min. Fick equation: This is computed by determining the amount of oxygen that has been lost between the arterial side and the venous side and multiplying by the cardiac output. Only marginal increases in oxygen content occur with saturations above 88-90% so this should be your goal. Remember: short-term risk of low oxygen is greater than short-term risk of administering too much oxygen. Oxygen Toxicity: Initial concern for oxygen toxicity came from the discovery that therapeutic oxygen causes blindness in premature babies with respiratory distress syndrome. The performance of a particular device depends: 1) flow rate of gas out of the device, and 2) inspiratory flow rate created by the patient. In the ideal device, gas flow exceeds the patient’s peak inspiratory flow so as not to entrain air from the atmosphere. Nasal cannula: The premise behind nasal cannula is to use the dead space of the nasopharynx as a reservoir for oxygen. There are a couple of problems with nasal cannula: 1) they need to be positioned at the nares, 2) effectiveness is influenced by the pattern of breathing - there appears to be little difference whether the patient is a mouth or a nose breather, but it is important that the patient exhale through their mouth. Initiating Mechanical ventilation Aim: Provide adequate ventilation and oxygenation without inducing barotrauma/volutrauma. Unstable hemodynamics: Hypotension is common after intubation–probably multi- factorial including pre–intubation hypovolemia which is increased by peri-intubation 8 analgesia and anesthesia, immediate effects of positive pressure ventilation on venous return; acidosis (hyperventilate pre-intubation). Agitation: Don’t forget that if paralytic agent has been use ensure patient also receives an anxiolytic/anmesic agent like benzodiazepine. Pressure Control Ventilation (see below) Uses Square Pressure wave form-hypothetically allows for recruitment of alveolar gas exchange units by maintaining inspiratory pressures for longer periods.

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Origin and insertion−sites where muscles originates and inserts 123 Human Anatomy and Physiology Example 100 mg solian amex, sternocleidomastoid−originates on sternum and clavicle and inserts on mastoid process of temporal bone buy solian 100 mg on line. Example, obturator externus 124 Human Anatomy and Physiology Principal skeletal muscles Although there are over 700 individual skeletal muscles in the human body, an appreciation and understanding of skeletal muscles can be accomplished by concentrating on the large superficial muscles and muscle groups. Refer to Figures 6-4 and 6-5 as you study the attachments and action of these muscles, and try to figure out why each has the name that it does. Head and neck muscles Muscle Origin Insertion Action Muscles of facial expression Occipitofrontalis Occipital bone Skin of eye brow Elevates eye brows orbicularis oculi Maxilla & frontal Skin around the Closes eye eye Orbicularis oris Maxilla & Skin around the Closes lip mandible lips Buccinator Mandible & Corner of mouth Flattens cheeks maxilla Zygomaticus Zygomatic bone Corner of mouth Elevates corner of muscles mouth Levator labii Maxilla Upper lip Elevates upper lip superioris Corrugator Frontal bone Skin of eye brow Lowers and draws supercilli together eye brows Depressor anguli Mandible Lower lip near Depresses corner oris corner of mouth of the mouth 125 Human Anatomy and Physiology Muscles of Temporal region Mandible Closes jaw mastication on Temporalis side of the skull Massetor Zygomatich arch Mandible Closes jaw Muscles that Occipital bone Scapula and Extends head move the head and Clavicle and neck rapezius vertebrae Sternocleidomas Sternum & Mastoid process Rotates head toid clavicle of temporal bone and flexes neck Table 6-2. Trunk muscles Muscle Origin Insertion Action Muscles that move the vertebral column Erector spinae Ilium, sacrum, Superior vertebrae Extend, abduct, and vertebrae Ribs rotate vertebrae Deep back Vertebrae Vertebrae Extend, abduct, and muscles rotate vertebrae Rectus Pubis Xiphoid process of Flexes vertebrae; abdominis ste- compress abdomen rnum & lower ribs External Rib cage Iliac crest & facia Flexes & rotates abdominal of vertebral column; oblique rectus abdominis compress abdomen Internal Iliac crest and Lower ribs and Flexes & rotates abdominal vertebrae facia of vertebral column; oblique rectus abdominis compress abdomen Transversus Ribcage, Xiphoid process of Compress abdomen abdominis vertebrae and sternum, facia of iliac crest rectus, abdominis and pubis 126 Human Anatomy and Physiology Table 6-3. Upper limb muscles Muscle Origin Insertion Action Muscles that move the scapula Trapezius Occipital bone Scapula clavicle holds scapula in place and vertebrae rotates scapula Serratus Ribs Medial border of Rotates scapula and anterior the pulls anteriorly scapula Muscles that move the arm Pectoralis Sternum, ribs, Tubercle of Adducts and flexes major and humerus arm clavicle Lattismus Vertebrae Tubercle of Adducts and extends dorsi humerus arm Deltoid Scapula and Shaft of Abducts, flexes, and clavicle humerus extends arm Teres major Scapula Tubercle of Adducts and extends humerus arm Infraspinalis Scapula Tubercle of Extends arm humerus Muscles that move the forearm Brachilis Shaft of humerus Coracoids Flexes and forearm process of ulna Biceps brachii Coracoids Radial process of tuberosity Supinates scapula Triceps brachii Shaft of humerus Olecranon Extends forearm and lateral border process of ulna of scapula Muscles that move the wrist and fingers 127 Human Anatomy and Physiology Anterior fore Medial Carpals,metacar Flex wrist, fingers and arm epicondyle pals, and thumb; pronate muscles phalanges forearm Posterior Lateral Carpals,metacar Extend wrist, fingers forearm epicondyle pals, and thumb; supinate muscles and phalanges forearm Intrinsic hand Carpals Phalanges Abduct, adduct, flex, muscles metacarpals and extend fingers and thumb Table 6-4. Lower limb muscles Muscle Origin Insertion Action Muscles that move the thigh Iliopsoas Ilium and Trochanter of Flexes thigh vertebrae femur Tensor fascia Anterior superior Lateral condyle Abducts thigh latae iliac of tibia spine Gluteus Ilium, sacrum, Lateral side of Extends and abducts maximus and coccyx femur thigh Gluteus Ilium Trochanter of Abducts thigh medius femur Adducter Pubis Femur Adduct thigh muscles of thigh Muscles that move the leg Quadriceps Anterior superior Tibial tuberosity Extends leg and flexes femoris Rectus iliac thigh femoris spine Vastus lateralis Femur Tibial tuberosity Extends leg Vastus Femur Tibial tuberosity Extends leg medialis 128 Human Anatomy and Physiology Vastus Femur Tibial tuberosity Extends leg intermedius (not shown in illustration) Sartorius Anterior superior Tibia Flexes leg and thigh iliac spine Hamstring Ischium and Fibula Flexes leg and muscles femur extends thigh Biceps femoris Semimembran Ischium Tibia Flexes leg and osus extends thigh Semitendinosu Ischium Tibia Flexes leg and s extends thigh Muscles that move the ankle and toes Tibialis anterior Tibia Tarsal and first Dorsiflexes foot metatarsal Deep anterior Tibia or fibula Phalanges, Extend toes leg muscles metatarsals, tarsals Gastrocnemius Medial and Calcaneus Plantar flexes foot lateral epicondyle of femur Soleus Tibia and fibula Calcaneus Plantar flexes foot Deep posterior Tibia of fibula Phalanges, Evert foot leg muscles metatarsals, tarsals Peroneus Fibula and tibia Tarsals and Evert foot Abduct, muscle Intrinsic Tarsals or metatarsals adduct, flex, and foot muscles metatarsals Phalanges extend toes 129 Human Anatomy and Physiology Figure 6-6 Superficial muscles, anterior (front view) (Source: Carola, R. Name and describe the major actions and innervations of the principal muscles of the head and neck, upper extremities, trunk, and lower extremities. Selected Key Terms The following terms are defined in the glossary: Accommodation Midbrain Acetylcholine Nerve Action potential Nerve impulse Afferent Neucleus Autonomic nervous system Neuron Axon Neurotransmitter Brain stem Ossicle Cerebellum Plexus 134 Human Anatomy and Physiology Cerebral cortex Pons Cerebrum Proprioceptor Choroid Receptor Cochlea Reflex Conjunctiva Refraction Cornea Retina Dendrite Sclera Diencephalons Semicircular canal Effector Spinal cord Efferent Stimulus Epinephrine Synapse Ganglion Thalamus Gray matter Tract Hypothalamus Tympanic membrane Lacrimal Ventricle Medulla oblongata Vestibule Meninges White matter General Function None of the body system is capable of functioning alone. All are interdependent and work together as one unit so that normal conditions within the body may prevail. Control of the body’s billions of cells is accomplished mainly by two communication systems: the nervous system and the endocrine system. Both systems transmit information from 135 Human Anatomy and Physiology one part of the body to another, but they do it in different ways. The nervous system transmits information very rapidly by nerve impulses conducted from one body area to another. The endocrine system transmits information more slowly by chemicals secreted by ductless glands into blood steam and circulated from glands to other parts of the body. Conditions both within and outside the body are constantly changing; the purpose of the nervous system is to respond to these internal and external changes (known as stimuli) and so cause the body to adapt to new conditions. The nervous system has been compared to a telephone exchange, in that the brain and the spinal cord act as switching centres and the nerve trunks act as cables for carrying messages to and from these centres. Cells of nervous system and their functions The two types of cells found in the nervous system are called neurons or nerve cells and neuroglia, which are specialized connective tissue cells. Dendrites are the processes or projections that transmit impulses to the neuron cell bodies, and axons are the processes that transmit impulses away from the neuron cell bodies. The three types of functional classification of neurons are according to the direction in which they transmit impulses. They do not conduct impulses to all parts of the body but only to two kinds of tissue-muscle and glandular epithelial tissue. Sensory neurons are also called afferent neurons; motor neurons are called efferent neurons, and interneurons are called central or connecting neurons. Myelin sheath is a white, fatty substance formed by Schwann cells that wrap around some axons outside the central nervous system. The fact that axons in the brain and cord have no neurilemma is clinically significant because it plays an essential part in the regeneration of cut and injured axons. Therefore the potential for regeneration in the brain and spinal cord is far less than it is in the peripheral nervous system. Impulse Generation and Conduction The Nerve Impulse The cell membrane of an unstimulated (resting) neuron carries an electric charge. Because of positive and negative ions concentrated on either side of the membrane, the inside of the membrane at rest is negative as compared with the outside. A nerve impulse is a local reversal in the charge on the nerve cell membrane that then spreads along the membrane like an electric current. The reversal occurs very rapidly (in less than one thousandth of a second) and is followed by a rapid return of the membrane to its original state so that it can be stimulated again. In other words, how does the axon of one neuron make functional contact with the membrane of another neuron? Within the branching endings of the axon are small bubbles (vesicles) containing a type of chemical known as a neurotransmitter. When stimulated, the axon releases its neurotransmitter in to the narrow gap, the synaptic cleft, between the cells. The neurotransmitter then acts as a chemical signal to stimulate the next cell, described as the postsynaptic cell. On the receiving membrane, usually that of a dendrite, sometimes another part of the cell, there are special sites, or receptors, ready to pick up and respond to specific neurotransmitters. Receptors in the cell membrane influence how or if that cell will respond to a given neurotransmitter. Acetylcholine (Ach) is the neurotransmitter released at the neuromuscular junction, the synapse between a neuron and a muscle cell. It is common to think of neurotransmitters as stimulating the cells they reach; infact, they have been described as such in this discussion. Note, however, that some of these chemicals act to inhibit the postsynaptic cell and keep it from reacting.

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Another way of looking at this is that the quality of the urine produced is an average over the time it takes to make that urine solian 100 mg free shipping. Normal Urine Characteristics Characteristic Normal values Color Pale yellow to deep amber Odor Odorless Volume 750–2000 mL/24 hour pH 4 purchase 50 mg solian otc. Normally, only traces of protein are found in urine, and when higher amounts are found, damage to the glomeruli is the likely basis. Unusually large quantities of urine may point to diseases like diabetes mellitus or hypothalamic tumors that cause diabetes insipidus. The color of urine is determined mostly by the breakdown products of red blood cell destruction (Figure 25. The “heme” of hemoglobin is converted by the liver into water-soluble forms that can be excreted into the bile and indirectly into the urine. A kidney stone or a cancer of the urinary system may produce sufficient bleeding to manifest as pink or even bright red urine. Diseases of the liver or obstructions of bile drainage from the liver impart a dark “tea” or “cola” hue to the urine. Most of the ammonia produced from protein breakdown is converted into urea by the liver, so ammonia is rarely detected in fresh urine. The strong ammonia odor you may detect in bathrooms or alleys is due to the breakdown of urea into ammonia by bacteria in the environment. About one in five people detect a distinctive odor in their urine after consuming asparagus; other foods such as onions, garlic, and fish can impart their own aromas! In diabetes mellitus, blood glucose levels exceed the number of available sodium-glucose transporters in the kidney, and glucose appears in the urine. Insufficient numbers of water channels (aquaporins) reduce water absorption, resulting in high volumes of very dilute urine. Urine Volumes Volume Volume Causes condition Normal 1–2 L/day Diabetes mellitus; diabetes insipidus; excess caffeine or alcohol; kidney disease; Polyuria >2. Diet can influence pH; meats lower the pH, whereas citrus fruits, vegetables, and dairy products raise the pH. Specific gravity is a measure of the quantity of solutes per unit volume of a solution and is traditionally easier to measure than osmolarity. Laboratories can now measure urine osmolarity directly, which is a more accurate indicator of urinary solutes than specific gravity. Protein does not normally leave the glomerular capillaries, so only trace amounts of protein should be found in the urine, approximately 10 mg/100 mL in a random sample. If excessive protein is detected in the urine, it usually means that the glomerulus is damaged and is allowing protein to “leak” into the filtrate. Finding ketones in the urine suggests that the body is using fat as an energy source in preference to glucose. Instead, the cells are forced to use fat as their energy source, and fat consumed at such a level produces excessive ketones as byproducts. It may sometimes appear in urine samples as a result of menstrual contamination, but this is not an abnormal condition. Now that you understand what the normal characteristics of urine are, the next section will introduce you to how you store and dispose of this waste product and how you make it. Urine is a fluid of variable composition that requires specialized structures to remove it from the body safely and efficiently. Blood is filtered, and the filtrate is transformed into urine at a relatively constant rate throughout the day. All structures involved in the transport and storage of the urine are large enough to be visible to the naked eye. This transport and storage system not only stores the waste, but it protects the tissues from damage due to the wide range of pH and osmolarity of the urine, prevents infection by foreign organisms, and for the male, provides reproductive functions. The urethra is the only urologic organ that shows any significant anatomic difference between males and females; all other urine transport structures are identical (Figure 25. The urethra in both males and females begins inferior and central to the two ureteral openings forming the three points of a triangular-shaped area at the base of the bladder called the trigone (Greek tri- = “triangle” and the root of the word “trigonometry”). In both males and females, the proximal urethra is lined by transitional epithelium, whereas the terminal portion is a nonkeratinized, stratified squamous epithelium. Voiding is regulated by an involuntary autonomic nervous system-controlled internal urinary sphincter, consisting of smooth muscle and voluntary skeletal muscle that forms the external urinary sphincter below it. Female Urethra The external urethral orifice is embedded in the anterior vaginal wall inferior to the clitoris, superior to the vaginal opening (introitus), and medial to the labia minora. It arises in the sacral region of the spinal cord, traveling via the S2–S4 nerves of the sacral plexus. Male Urethra The male urethra passes through the prostate gland immediately inferior to the bladder before passing below the pubic symphysis (see Figure 25. It is divided into four regions: the preprostatic urethra, the prostatic urethra, the membranous urethra, and the spongy or penile urethra. During sexual intercourse, it receives sperm via the ejaculatory ducts and secretions from the seminal vesicles. Paired Cowper’s glands (bulbourethral glands) produce and secrete mucus into the urethra to buffer urethral pH during sexual stimulation.